ADHD? Or, Could It Be A Sleep Disorder?

Today, we’re re-exploring a topic that we’ve touched on before: the connection between ADHD and sleep disorders. You might be wondering why, as a parent of a baby or a young toddler, you should even bother thinking about diagnoses like ADHD. But as we pointed out in a past article,

In today’s article, we’ll take a look at one family’s story of how a sleep disorder proved to cause far more serious problems than they could’ve imagined.

The Graham Family’s Story

Recently, the Vancouver Sun spotlighted the Graham family. The article focuses broadly on how sleep disorders in children are often misdiagnosed as ADHD; it focuses specifically on the experience of 6 year old Emmy Graham.

Her parents explain that Emmy was always a restless, active child (even in the womb!) But that restlessness caused sleep issues immediately after Emmy’s birth:

As an infant, Emmy would sleep only eight hours a day — in fits and starts, never in a stretch. There were no naps after the age of one and maybe six or eight hours of restless sleep a day. Toddlers are supposed to spend about half of every 24 hours asleep.

Without that much-needed rest, Emmy threw daily tantrums and screaming fits. Her development stalled; even at age five she couldn’t hold a pencil. She was diagnosed with a developmental co-ordination disorder, attention deficit hyperactivity disorder (ADHD), attachment disorder and anxiety.

“Her brain wasn’t sleeping enough to lay down the motor pathways for co-ordination,” says Kirsten [Emily’s mother]. “None of the pieces can come together for kids if they’re not sleeping.

That’s absolutely true — babies and toddlers require adequate amounts of sleep each day in order to grow and develop properly. We’ve written before about how prolonged lack of sleep for a baby or toddler can lead to developmental and behavior problems, and even depression.

The Grahams struggled with Emmy’s various diagnoses for years, trying to sort out why Emmy wouldn’t sleep, and trying to manage her symptoms. It was a heartbreaking time for parents Kristen and Rob. Emmy’s symptoms grew worse, to the point where she wouldn’t allow her parents to comfort her, or even to touch her. Some of Emmy’s psychiatrists went so far as to make the Grahams feel they were to blame for Emmy’s issues:

…child psychiatrists told Kirsten that her lack of attachment to her child was the problem.

“I remember time and time again in the psychologist’s office saying, ‘but she came this way.’

“I won’t discount that there was a problem in our relationship, but it starts to grow out of having a child that won’t look at you, won’t touch you, (whom) you can’t comfort … I was desperate as a mother that I couldn’t care for her,” Kirsten says.

“In hindsight, it’s obvious that a child that won’t look at you and won’t be comforted is in physical distress,” says Rob.

For the Grahams, ADHD Was the Symptom, but RLS Was the Cause

It wasn’t until they met Dr. Osman Ipsiroglu that the Grahams got the answer they so desperately needed. Whereas other doctors and experts had been focused on Emmy’s symptoms, and had been diagnosing those, Dr. Ipsiroglu was able to uncover the root cause of Emmy’s problems:

Finally, a year ago, Osman Ipsiroglu, a Vancouver pediatrician with expertise in sleep problems, diagnosed Emmy with restless leg syndrome, a common condition for adults, but rarely recognized in children.

Instead, it and other under-recognized sleep disorders are lumped into the growing number of ADHD cases in B.C. [British Columbia], he say, adding that pediatricians and child psychologists should rule out sleep disorders before making an ADHD diagnosis.

Emmy’s experience is common, according to Dr. Ipsiroglu. He says a number of children who are diagnosed with ADHD actually have sleep disorders:

“We believe that there is a tremendous overlap with ADHD … If you don’t sleep well, you will have some behavioural issues the next day. You will be grumpy, you will be less tolerant, possibly, and this is what happens with the kids. If they have chronic sleep deprivation, they may have an ADHD-like presentation.”

ADHD Misdiagnosis Is Common and Understandable, but It Can Be Dangerous

The Graham family and Dr. Ipsiroglu recognize that it can be hard to distinguish between normal bedtime-resistance and true sleep disorders, and that currently, the medical community isn’t equipped to properly diagnose sleep disorders in children:

Untangling the difference between run-of-the-mill ‘I don’t want to go to bed’ pushback from a three-year-old and a child with a serious medical issue is not easy, Ipsiroglu admits.

He suggests an individualized approach to each child, something that’s effectively impossible right now in B.C. because there aren’t enough health professionals who know what they’re looking for.

Still, it’s important for parents and medical professionals to realize that misdiagnosing a sleep disorder like RLS, and applying an ADHD diagnosis instead, can create big problems:

A misdiagnosis isn’t benign. If typical stimulant medications for ADHD are prescribed, the itching, crawling, creeping feelings of restless leg syndrome are amplified.

How To Avoid an ADHD Misdiagnosis

Let’s be clear — we’re not saying that every ADHD diagnosis can be traced to a sleep disorder. Not at all. As Dr. Merrill Wise, a pediatric neurologist and sleep medicine specialist, puts it,

“No one is saying that ADHD does not exist, but there’s a strong feeling now that we need to rule out sleep issues first.”

So, what can we do, as parents, to prevent a misdiagnosis like Emmy Graham’s? First, we can educate ourselves on what sleep disorders are, and what they look like. Common sleep disorders for children include:

As parents, we can also seek medical help when we think it’s necessary. If you suspect your child has a sleep disorder like sleep apnea or Restless Leg Syndrome, seek out appropriate medical treatment. Surgery to remove tonsils and adenoids can help with apnea, and there are several types of medications that can alleviate RLS.

Finally, one of the best things we can do as parents is to tackle our children’s sleep issues head-on. True sleep disorders often require medical intervention, but plenty of other children suffer from sleep issues that can be solved with some basic sleep training.

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Comments

MBsays

The link to the alleged connection between ADHD and sleep issues does not support what you claim on this site. The studies that ADHD may cause sleep issues in teenagers…. And one case of anything does not show anything. I think you are offering misleading suggestions here. Um… I wonder why? Could it be you want us to buy your sleep solutions??

Emily DeJeusays

@ MB — I’m sorry you feel that we’re not presenting reliable information, or that you feel we’re presenting information in an effort to ‘mislead’ people into buying our services. That’s certainly not our intention. And since we work only with babies and toddlers, and ADHD typically isn’t diagnosed until age 5 or 6, this isn’t something we deal with directly at all.

However, there has been emerging research that ADHD is closely connected to sleep problems:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218783/ (2011 review of several studies on the connection between ADHD and sleep; paper concludes that there is a significant connection between ADHD and sleep, and that proper diagnosis and treatment of sleep disorders and children and young adults has been shown to improve ADHD symptoms).

I want to assure you that the story we’re reporting on here isn’t an isolated incident. A number of studies have been done on this topic in the last 10 years, and there seems to be a general consensus among medical experts that sleep disorders and ADHD are connected in some way. However, more research needs to be done before anyone can say definitively how they’re connected.

It’s our hope that in presenting current research and stories like this, we’ll keep our readers and clients abreast of the latest sleep-related news. We also hope that articles like this will help reinforce something we believe strongly: that chronic, persistent sleep problems shouldn’t be blown off or ignored. Chronic sleep deprivation in babies and toddlers has been known to produce physical problems (obesity) and psychological problems (behavioral issues) in later childhood. Now, there’s evidence indicating that chronic sleep deprivation in the early years can lead to higher rates of ADHD among school-aged children. We certainly want our readers to have that information, not so they’ll purchase our services, but so they’ll take their children’s sleep seriously.

I hope this helps give you a better sense of what we’re trying to accomplish with this article, MD, and of the research and resources that we used to write it.

Jennifersays

Emily’s response is well written. As an adult with ADHD, I am well aware that my symptoms are worse when I have not slept well; the symptoms for ADHD closely resemble those of sleep deprivation, hypothyroid disorder, and likely a host of other problems. I fear too many doctors are too eager to close one case and move on to the next – they must truly listen to their patients and consider all possibilities before making a diagnosis and handing out prescriptions. I know (all too well!) that ADHD is real (and frequently missed in kids who cope well… that’s a whole ‘bother discussion) but I also believe it is all too commonly misdiagnosed.

Emily DeJeusays

@ Jennifer — thanks for weighing, and for sharing your unique perspective! I agree; I think lots of doctors feel pressure to get patients in and out fairly quickly, and most don’t have time to delve deeply into a patient’s complete medical history. And frankly, I think most doctors don’t jump right to ‘sleep’ when discerning what underlying issues might be causing a specific problem.

Thanks again for commenting, Jennifer! Much appreciated.

Arlenesays

Great article and suggestions. I work in early intervention (ages 0-3) and I’m seeing ADHD diagnoses with some of my kids already. Often regular sleeping, waking and other routines are never even taken into account when giving some diagnoses. There are lots of great doctors out there specialized in pediatric sleep, this would be a good thing to rule out. Thank you!

Emily DeJeusays

@ Arlene — wow! That seems early for an ADHD diagnosis; I always thought doctors were reluctant to diagnose until 5 or 6. But maybe the prevailing opinion is changing? You’d know better than I would.

You make a really great point here — that sleep usually isn’t a factored in when diagnosing a medical issues. I once worked with a top-notch physical therapist who told the therapists she trained that one of their first questions to their patients should be, “How are you sleeping these days?” In her opinion, a significant part of treating a patient’s physical pain was ensuring that the patient was getting adequate, restorative sleep every single night. I thought that insight was so brilliant on her part. And I think it holds true for kids as well; healthcare providers would do well to ask parents “How much sleep is your child getting?” before making some behavioral and mental health diagnoses.

Thanks for weighing in, Arlene!

Mollysays

My son is only 10 months old, so he obviously hasn’t been diagnosed with ADHD. But seeing this list of possible sleep disorders is really helpful. He has been an awful sleeper since day one, and my husband and I have been completely baffled. We feel like we have done everything “right”… a consistent night routine, low key time to wind down before naps, putting him to bed drowsy but awake, no sleep associations. However, he wakes up crying (and sometimes screaming) 8-12 times every single night. He starts waking up about 35 minutes after he goes down. He is not calmed by our presence, so it isn’t separation anxiety. He WANTS to be asleep, but he can’t. Sometimes he cries 4-5 hours at night. I have made many desperate trips to the doctor, but it is always contributed to teething or an ear infection or just being a bad sleeper. My husband and I are so miserably exhausted. We get about 4 hours of interrupted sleep a night. And I am so worried about my little one. I don’t know what to do because the doctors aren’t taking us seriously

Emily DeJeusays

@ Molly — This must be just awful for you and your husband. I’m so sorry! Truly, from what you say here, it sounds like you’re doing all the right things, but that nothing you do is yielding good results. It also sounds like you’ve tried to seek medical help for this but have been brushed off.

I’d say your instincts are serving you well here, Molly. This doesn’t sound like standard 10 month old behavior to me, especially considering you’ve gone out of your way to create healthy sleep habits, and to avoid sleep associations. It also sounds like your son just isn’t getting the sleep he needs, and you’re right to be concerned about that.

This is a link to the National Sleep Foundation’s list of sleep professionals in the U.S. (I’m assuming you’re based in the U.S.; correct me if I’m wrong!) This may be a good reference for you, since your son’s doctors don’t seem to be taking his lack of sleep seriously, and probably won’t have much expertise in this particular area.

I’d suggest browsing the list of sleep professionals (virtually all of whom are medical doctors) and calling a few in your area. Check to see if they work with children, and what their terms are (what kind of insurance they take, if you need a referral from a family doctor, etc.) If you go this route, you’d be able to get help from a doctor who specializes in sleep issues, and who would definitely take your son’s situation seriously.

This is just a suggestion, of course. I wish the team here at Baby Sleep Site could help you with this, but since we’re not trained medical professionals, we can’t help with sleep disorders. If you had a scheduling problem, or big-time sleep associations, or something like that, we could help. But it doesn’t sound like that’s what you’re dealing with.

Hope this helps, Molly! Do check back in and let us know what happens with your son. Best of luck to you and to your husband.

Mollysays

Thank you so much! I will keep you updated! I devour the info on this site

Emily DeJeusays

@ Molly — Happy to help! And so glad to know you find the site to be a valuable resource.

Sophia’s Baby Sleep Story

FREE Guide:
Five Ways To Help Your Child Sleep Through the Night

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